1. Upper abdominal symptoms that persist despite an appropriate trial of therapy
2. Upper abdominal symptoms associated with other symptoms or signs suggesting structural disease (e.g., anorexia and weight loss) or new-onset symptoms in patients older than 50 years of age
3. Dysphagia or odynophagia
4. Esophageal reflux symptoms that persist or recur despite appropriate therapy
5. Persistent vomiting of unknown cause
6 Other diseases in which the presence of upper GI pathology might modify other planned management. Examples include patients who have a history of ulcer or GI bleeding who are scheduled for organ transplantation, long-term anticoagulation, or nonsteroidal anti-inflammatory drug therapy for arthritis and those with cancer of the head and neck
7. Familial adenomatous polyposis syndromes
8. For confirmation and specific histologic diagnosis of radiologically demonstrated lesions:
• Suspected neoplastic lesion
• Gastric or esophageal ulcer
• Upper tract stricture or obstruction
9. GI bleeding:
• In patients with active or recent bleeding
• For presumed chronic blood loss and for iron deficiency anemia when the clinical situation suggests an upper GI source or when colonoscopy does not provide an explanation
10. When sampling of tissue or fluid is indicated
11. Selected patients with suspected portal hypertension to document or treat esophageal varices
12. To assess acute injury after caustic ingestion
13. To assess diarrhea in patients suspected of having small-bowel disease (e.g., celiac disease)
14. Treatment of bleeding lesions such as ulcers, tumors, vascular abnormalities (e.g., electrocoagulation, heater probe, laser photocoagulation, or injection therapy)
15. Removal of foreign bodies
16. Removal of selected lesions
17. Placement of feeding or drainage tubes (e.g., peroral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy)
18. Dilation and stenting of stenotic lesions (e.g., with transendoscopic balloon dilators or dilation systems using guidewires)
19. Management of achalasia (e.g., botulinum toxin, balloon dilation)
20. Palliative treatment of stenosing neoplasms (e.g., laser, multipolar electrocoagulation, stent placement)
21. Endoscopic therapy of intestinal metaplasia
22. Intraoperative evaluation of anatomic reconstructions typical of modern foregut surgery (e.g., evaluation of anastomotic leak and patency, fundoplication formation, pouch configuration during bariatric surgery)
23. Management of operative complications (e.g., dilation of anastomotic strictures, stenting of anastomotic disruption, fistula, or leak in selected circumstances)
Table 1.2
Alarm symptoms prompting EGD
Unintentional weight loss |
Dysphagia |
Odynophagia |
Hematemesis/Melena |
Refractory acid reflux |
Procedural Technique
It should be stressed that the technique advocated herein is not the only or ideal manner in which to perform an upper endoscopy, and individual techniques vary (Video 1.1).
The upper endoscope instrument controls consist of insertion section with optical system which is 9.2 mm in diameter, air/water buttons, a control head for left/right (small wheel) deflection, a control head for up/down deflection (big wheel), biopsy channel port (two ports in large therapeutic endoscopes), Narrow Band Imaging (NBI) or similar electronic enhancement button, and video/picture controls which can include zoom or near focus, depending on the instrument. Using the thumb, index, and middle fingers, most buttons and knobs can be controlled simultaneously with ease. Beginners should learn on how to set up the endoscopy cart, adjusting the light settings and connecting accessories such as heating probe or APC to an electrosurgical generator as needed.
Prior to starting endoscopy, the patient should be positioned in the left lateral decubitus position with the head of the bed elevated and a bite block should be inserted to allow the scope to pass through when the patient is sedated. The bite block protects the patient’s teeth from the endoscope and protects the endoscope from the patient’s teeth. Endoscopists should be familiar with intubating the esophagus in supine patients as this if often essential to the performance of upper endoscopy in ICU patients. Most EGD exams involve the identification of specific landmarks to ensure the completeness of the procedure (see Table 1.3).
Table 1.3
Identification of landmarks
Vocal cords/hypopharynx |
Top of gastric folds |
Z line |
Greater and lesser curvature of stomach |
Pyloric orifice |
Duodenal bulb |
Second part of duodenum |
Post-surgical anatomy |
Esophageal Intubation
The most challenging part of upper endoscopy for beginners is often the intubation of the esophagus. The intubation of esophagus should be done under direct visualization. The endoscope should, in general, not be advanced blindly or with undue force. In patients undergoing conscious sedation or in minimally sedated patients, sometimes it is useful to ask the patient to swallow when the scope enters the posterior pharynx to help relax the upper esophageal sphincter. Some endoscopists use the left index or middle finger to direct the scope into the posterior pharynx. Flexing the neck at this time may be useful to facilitate the endoscope passage to the posterior pharyngeal area.
Direct Visualization of Hypopharynx, Upper Esophageal Sphincter
The landmarks to guide entry into the upper esophageal orifice are present in and can be directly identified in the hypopharynx. In practice, this consists of visualizing the vocal cords and piriform sinuses and locating the upper esophageal sphincter (UES) just posterior to these. The UES is usually located 15–18 cm from the incisors, at the level of thyroid cartilage.
Despite adequate visualization of landmarks, occasionally it may difficult to intubate the UES, especially if the patient is inadequately sedated, or having issues with prominent cervical spine or neck mobility or has had prior head and neck surgery for oncologic issues.
Zenker’s Diverticulum
During endoscopy, the presence of a Zenker’s diverticulum often creates difficulty in UES intubation due to either compression of the normal esophageal lumen and/or obscuring the lumen from view. In addition, some patients have a prominent cricopharyngeal bar. It is prudent to consider and think about a possibility of a Zenker’s diverticulum in elderly patients to reduce the risk of the procedure.
Examination of Esophagus
Under direct vision, the lumen of the esophagus is carefully visualized. This is done by insertion of the endoscope in the esophagus, along with air insufflation and direct observation. The scope can be gently torqued clockwise and anticlockwise manner to examine all the sides of the esophagus. Use of the tip deflection knobs is usually not necessary in the esophagus, except when performing some interventions such as taking biopsies. The aortic pulsation is normally located approximately at 20–25 cm from the upper incisors.
Identifying the Gastroesophageal Junction (GEJ)/Squamo-Columnar Junction/Z Line
In adults, the GEJ is typically located approximately 35-40 cm from the upper incisors. This is an important mark to remember. The location of the top of the gastric folds can be noted, and the distance from the GEJ to the upper incisors can be noted. The squamo-columnar junction is represented by the clear demarcation of the pale pearl colored esophageal mucosa to salmon pink gastric mucosa and called as “Z line.” If salmon-colored pink mucosa extends cephalad from top of gastric folds, this suggests Barrett’s esophagus.
Hiatal Hernia
Normally, the diaphragmatic hiatus squeezes the esophagus at or just below the GE junction. The position of the hiatus can be visualized by the contraction waist seen the lower esophagus, which is more easily observed when the patient sniffs or during deep breathing. A hiatal hernia is diagnosed if the Z line is more than 2 cm above the hiatus. Hiatal hernia also typically examined and confirmed during retroflexion in the stomach (see Fig. 1.1).
Fig. 1.1
Retroflexion in stomach
Examination of the Stomach
After esophageal evaluation, the endoscope is then passed into the lumen of the stomach itself. When patient is in left lateral position, this maneuver is usually easily accomplished. Intubation into the stomach is confirmed by identification of the characteristic rugal folds.
Identifying Lesser/Greater Curvature/Anterior/Posterior
Once the endoscope passes the GE junction, it usually enters the stomach along the lesser curvature, and the light shines on the greater curvature demonstrating the longitudinal rugal folds. The gastric wall to the left usually represents the anterior gastric wall, while the rightward stomach represents the posterior gastric wall.
Suction, Irrigation, and Air Insufflation
As a general rule, a good first thing to do after entering the stomach is to suction and remove any residual fluid in the fundus to reduce the risk of aspiration. Sometimes there may be retained food, blood, or mucus impairing mucosal visualization. A thorough water irrigation, with alternating suction helps to improve mucosal evaluation. Simethicone drops mixed in the water used for irrigation augment visibility by clearing gas bubbles or these can be washed away with a power flush, if available. Although air insufflation is necessary to distend the stomach for better visualization, too much air insufflation should be avoided as it may cause retching, vomiting, and even mucosal trauma from acute distension.
Examination of the Pylorus and Incisura
After suctioning, and optimally distending the stomach, the endoscope should be directed to the pylorus. The pylorus and the peri-pyloric area are examined carefully for any mucosal irregularities that would warrant biopsy or treatment. After slightly withdrawing from the pylorus, the tip is deflected upwards to examine the incisura angularis.
Examination of Gastric Body and Antrum
With an adequately distended stomach, the antrum and the body can then be carefully examined along both the lesser and greater curvatures, and along their anterior and posterior walls. The endoscope should be withdrawn almost up to the GE junction for a complete “long view” examination.
Retroflexion in the Stomach
After optimal distension of stomach with air, retroflexion is performed in order to view areas such as the fundus, cardia, and GE junction that otherwise would have limited tangential visualization during initial entry into the stomach. Also, selective examination of the incisura angularis is frequently performed again in the retroflexed view. In retroflexion, the endoscope is rotated and using counterclockwise and clockwise rotation the entire GE junction, lesser curve, and gastric cardia can be examined effectively (see Fig. 1.1).
Pyloric Intubation
As in esophageal intubation, pyloric intubation should be performed under direct visualization without blind advancement. The pyloric channel is visualized easily by identifying the radiating gastric folds which converge to the pyloric orifice (see Fig. 1.2).
Fig. 1.2
Pyloric orifice with converging folds
Intubation of the pylorus may be difficult at times, due to spasms (commonly) or the presence of pyloric stenosis (rarely). Sometimes an ulcer in the pyloric channel may make pyloric intubation difficult or can produce bleeding, which is usually limited. By using gentle air insufflation, the pylorus may be visualized and the scope tip is gently placed into the pyloric orifice and with slight pressure the endoscope usually easily passes through the duodenum.
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